Deep vein thrombosis ; symptoms , causes, treatment

Types of Venous Disorders

Thrombophlebitis and Deep Vein Thrombosis

Thrombophlebitis is a disorder typically affecting the lower extremities and caused by thrombosis (the development/ formation of a blood clot—i.e., a thrombus). It is characterized by acute inflammation with partial or complete occlusion of a superficial or deep vein. Lower extremity venous thrombosis can occur in the superficial vein system (greater or small saphenous veins) or the deep vein system (popliteal, femoral, or iliac veins) . A thrombus in one of the superficial veins in the calf usually is small and resolves without serious consequences. In contrast, thrombus formation in a deep vein in the calf or more proximally in the thigh or pelvic region, known as a deep vein thrombosis (DVT), tends to be larger and can cause serious complications. When a clot breaks away from the wall of a vein and travels proximally, it is called an embolus. When an embolus affects pulmonary circulation, it is called a pulmonary embolism, which is a potentially life-threatening disorder.33,67 A lower extremity DVT is a common complication after musculoskeletal injury or surgery, prolonged immobilization,

or bed rest and is attributed to venous stasis, injury to and inflammation of the walls of a vein, or a
hypercoagulable state of the blood.

Chronic Venous Insufficiency

Chronic venous insufficiency is defined as inadequate venous return over a prolonged period of time. It may begin after a severe episode of DVT, may be associated with varicose veins, or may be the result of trauma to the lower extremities or blockage of the venous system by a neoplasm.  In all of these disorders damaged or incompetent valves in the veins prevent or compromise venous return, leading to venous hypertension and venous stasis in the lower extremities. Chronic pooling of blood in the veins causes inadequate oxygenation of cells and removal of waste products. This, in turn, leads to necrosis of tissues and the development of venous stasis ulcers.

Deep vein


Clinical Manifestations of Venous Disorders

Deep Vein Thrombosis and Thrombophlebitis:

 

Signs and Symptoms

 

During the early stages of a DVT, only 25% to 50% of cases can be identified by clinical manifestations, such as dull aching or severe pain, swelling, or changes in skin temperature and color, specifically heat and redness. Although edema in the vicinity of the clot may be present, it may be too deep to palpate. If the clot is in the calf (distal DVT), pain or tenderness of the calf may be felt with passive dorsiflexion of the affected foot (Homans’ sign). However, the sensitivity of this test is poor and often reflects a false-negative or false-positive finding. Only measurement by ultrasonography, venous duplex screening,

or venography can confirm a DVT.

Pulmonary Embolism: Signs and Symptoms

As described previously, pulmonary embolism is a possible consequence of DVT. Risk factors for pulmonary embolism are similar to those already identified for DVT. The signs and symptoms of pulmonary embolism vary considerably depending on the size of the embolus, the extent of lung involvement, and the presence of coexisting cardiopulmonary conditions.84 The hallmark signs and

symptoms are a sudden onset of shortness of breath (dyspnea), rapid and shallow breathing (tachypnea), and chest pain located at the lateral aspect of the chest that intensifies with deep breathing and coughing. Other signs and symptoms include swelling in the lower extremities, anxiety, fever, excessive sweating (diaphoresis), a cough, and blood in the sputum (hemoptysis). When a patient presents with signs or symptoms of possible pulmonary embolism, immediate medical referral is warranted for a definitive diagnosis.

Chronic Venous Insufficiency:

 Signs and Symptoms

Dependent, peripheral edema occurring with long periods of standing or sitting is a common manifestation of chronic venous dysfunction. Edema decreases if the limb is elevated. Patients often report dull aching or tiredness in the affected extremity. If the insufficiency is associated with varicose veins, venous distention (bulging) also is notable. When edema persists, the skin becomes less supple over time and takes on a brownish pigmentation.

Examination and Evaluation

of Venous Sufficiency

As with arterial disorders, a complete history and systems review help determine the presence of a venous disorder.  These tests complement a comprehensive integumentary and neuromuscular examination that includes skin integrity, mobility, color, texture, temperature, vital signs including peripheral pulses, sensation, pain, functional mobility, ROM, strength, and cardiopulmonary endurance.

Girth Measurements

Circumferential measurements of the involved and uninvolved limbs are taken to determine the presence and extent of edema.  Measurements are taken at anatomical landmarks or at predetermined and consistent distances apart (e.g., 8 or 10 cm apart).

Deep vein


Competence of the Greater Saphenous

Vein (Percussion Test)

Evaluating the valves of the saphenous vein is a common test used if a patient has symptomatic varicose

veins.

Procedure

 Ask the patient to stand until the veins in the legs appear to fill. While palpating a portion of the saphenous vein below the knee, sharply percuss a portion of the vein above the knee. If valves are not functioning adequately, the examiner feels a backflow of fluid distally under the palpating fingertips.

Tests for Deep Vein Thrombosis

The following tests determine the possible presence of a DVT in a lower extremity.

Homans’ Sign

Procedure

 With the patient supine and the knee extended, passively dorsiflex the ankle and gently squeeze the calf muscles. If pain occurs in the calf, Homans’ sign is positive, indicating the possible presence of a DVT. However, this is not a definitive test. Homans’ sign has been found to be positive in more than 50% of subjects who did not have a DVT. In addition, it has been shown to be positive in fewer than one-third of patients with a confirmed DVT in the calf.

Application of a Blood Pressure

Cuff Around the Calf

Procedure

 Inflate the cuff gradually until the patient experiences calf pain. A patient with acute thrombophlebitis usually cannot tolerate pressures above 40 mm Hg.

Additional Special Tests

Tests designed to confim the presence of a venous disorder are performed and analyzed by the patient’s physician or a practitioner with specialized training. Tests include ultrasonographic imaging, Doppler measurement of blood flow, and venous duplex scanning (all of which are noninvasive) and venography (phlebography), an invasive procedure. Venography involves injecting radiopaque dye and radiographic visualization of the venous system.

 

Prevention of Deep Vein

Thrombosis and Thrombophlebitis

Every effort should be made to prevent the occurrence of a DVT and subsequent thrombophlebitis, particularly in patients at risk. The following interventions are implemented

to reduce the risk of a DVT. Prophylactic use of anticoagulant therapy (high-molecular- weight heparin) for the high-risk patient (e.g., the patient who has undergone lower extremity surgery or

who is on bed rest) Initiation of ambulation as soon as possible after surgery, preferably no more than a day or two postoperatively Elevating the legs while lying supine and on a footstool

or ottoman when sitting No prolonged periods of sitting, especially for the

patient with a long-leg cast Active “pumping” exercises (active dorsiflexion, plantarflexion,

and circumduction of the ankle) regularly throughout the day while lying supine in bed Use of compression stockings to support the walls of the veins and minimize venous pooling

For patients on bed rest, use of a sequential pneumatic compression unit

Management of Deep Vein

Thrombosis and Thrombophlebitis

If the presence of DVT and resulting thrombophlebitis is confirmed, immediate medical intervention is essential to reduce the risk of pulmonary embolism. Initial management includes administering anticoagulant medication, placing the patient on complete bed rest, elevating the involved extremity, and using graduated compression stockings. The reported time frame for bed rest varies from

2 days to more than a week.3 Box 24.7 summarizes the guidelines for management of acute DVT and thrombophlebitis During the period of bed rest, exercises usually are contraindicated because movement of the involved extremity may cause pain and is thought to increase congestion in the venous channels when tissues are inflamed. However, the optimal timing of when it is prudent to discontinue bed

rest and resume ambulation after initiating anticoagulant therapy is in question.

 

Management of Chronic Venous

Insufficiency and Varicose Veins

Patient education is fundamental in the management of chronic venous insufficiency and varicose veins. A patient must be advised on how to prevent dependent edema, skin ulceration, and infections. The therapist may be involved in

(1) measuring and fitting a patient for a pressure gradient

support garment

 (2) teaching the patient how

to put on the garment before getting out of bed;

 (3) setting

up a program of regular exercise

(4) teaching the

patient proper skin care.

 

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